By Jeanne Faulkner, R.N., a labor nurse and writer for FitPregnancy.You can read more from Jeanne at fitpregnancy.com/labornurse.
In the U.S. today, about 4 percent of babies are breech at full term, which means they're in position to exit the uterus feet- or butt-first rather than headfirst. Before 1959, virtually all such babies were safely delivered vaginally; today, most are born by Cesarean section. But as more mothers and babies are experiencing sometimes serious complications associated with surgical deliveries (in 1970, the C-section rate was 5.5 percent; today it's 34 percent), some experts are re-evaluating their position regarding breech births.
Beginning in the 1960s, obstetricians gradually shifted the way they delivered breech babies because they preferred the predictability and the presumed greater safety of a C-section birth. But not every doctor jumped on the C-section wagon immediately; many continued favoring vaginal breech births. That is, until the Hannah Term Breech Trial (TBT) published in 2000 brought them to a screeching halt. The TBT followed 2,083 breech babies in 26 countries, randomly assigned to either vaginal or planned C-section delivery. Early data suggested fewer newborn deaths and injuries occurred in the C-section group. The impact of this study was stunning, says Heather Weldon, M.D., an OB-GYN at Southwest Medical Group OB/GYN Associates in Vancouver, Wash. Within months, breech C-sections went from 50 percent to 80 percent and, by 2006, 90 percent. Then, we found out the study was flawed.
In fact, critics began poking holes in the TBT immediately after its publication. For example, some poor outcomes attributed to vaginal delivery occurred in birth centers that used substandard techniques or unskilled birth attendants. Some babies had genetic defects or were premature. In short, most weren't injured because they were delivered vaginally, but because of other factors. Further study indicated that most of the babies recovered fully from their birth injuries regardless of delivery method, and researchers also hadn't factored in the increased health risks resulting from C-sections.
"The data actually support vaginal breech birth as safe in certain scenarios and not in others", says Amy M. Romano, C.N.M., M.S.N., associate director of programs at Childbirth Connection, a nonprofit organization dedicated to promoting evidence-based maternity care. The results should have supported informed decision-making, but instead, hospitals reacted by taking that choice away from women. Another unfortunate result was that medical schools quit teaching vaginal breech delivery skills to entire generations of new doctors. Any care provider can get surprised by a breech baby during labor, but many doctors don't know what to do and that's dangerous, says Ina May Gaskin, C.P.M., founder of The Farm Midwifery Center in Tennessee and author of Ina May's Guide to Childbirth (Random House) and Birth Matters (Seven Stories Press).
Making that baby flip
A baby can be breech off and on throughout pregnancy without causing concern. But after 32 weeks, it might be a good idea to try to reroute him if you want to avoid a C-section. If he's still breech at 35 weeks, care providers tend to worry, and if 37 weeks comes and goes, it's time to take action: The closer it gets to your due date, the less likely it is for your baby to flip because there's just not enough wiggle room.
Three types of breech babies
1} Frank Breech The baby's bottom faces the cervix and his legs are straight up. This is the most common type and can sometimes be delivered vaginally.
2} Footling Breech The baby's feet are in the birth canal. This is the second most common type and is generally unsafe to deliver vaginally because of potential cord complications.
3} Complete Breech The baby's bottom faces the cervix. His legs are bent at the knees, and his feet are near his bottom. The least common type, these babies can sometimes be delivered vaginally.
The following three methods can be tried at 32 weeks or later:
The tilt. Using cushions placed on the floor or an ironing board propped up against the seat of your couch, lie with your hips elevated about 1½ feet above your head. Do this for 10 to 15 minutes three times a day, preferably when your baby is active. There are no reliable statistics, but according to Gaskin, It works a lot of the time.
The Webster Technique. This is a gentle chiropractic adjustment to the pelvis and sacrum that reduces uterine torsion [twisting] and balances the pelvic muscles so that the baby can move into a more optimal position for birth, says Heather Yost, D.C., a chiropractor at Yost Family Chiropractic in Urbandale, Iowa. It usually takes four to 10 adjustments, but some babies turn after just one attempt. The Journal of Manipulative and Physiological Therapeutics reports the technique has a success rate of 82 percent.
Pulsatilla is a homeopathic remedy that stimulates the uterus to settle baby headfirst. It's best to see a naturopathic physician (N.D.) or a homeopath, though some midwives feel comfortable recommending specific doses and instructions. It's safe and sometimes works, Gaskin says.
The following two techniques should not be tried before 37 weeks because they may stimulate labor:
External cephalic version, performed by either a doctor or midwife, repositions the baby by pushing on the mom's abdomen and the baby's head. It's like a deep abdominal massage. Sometimes we relax the uterus with medication, Weldon says. Then we lift the baby's body with one hand, get the opposite hand on the baby's head and encourage a somersault. An epidural may be given to minimize discomfort during the procedure. According to the American College of Obstetricians and Gynecologists, the average success rate is 58 percent.
Moxibustion, a technique performed by acupuncturists, uses heat from a burning herb, mugwort, to stimulate an acupuncture point on the outside of the smallest toe; this increases fetal activity. Studies show that moxibustion is 30 percent to 36 percent more likely than other methods to make a baby turn head-down, with some small studies indicating that its success rate may be higher than 80 percent.
If you're close to your due date, your baby is still breech and you want to avoid a C-section, surgery may be your only option unless you can find a doctor or midwife who is qualified and willing to deliver him vaginally or you don't meet the criteria for a safe vaginal birth. For details about one hospital's pioneering program, see below.
If you want a vaginal delivery
Oregon Health & Science University (OHSU) in Portland is among a few hospitals nationwide to support vaginal breech delivery. Without hospital-based options, some patients attempt high-risk deliveries at home, says Leonardo Pereira, M.D., OHSU's chief of maternal-fetal medicine. OHSU has established safety criteria for patients, and we are training clinicians to deliver breeches vaginally in order to make the service available at more hospitals in the future.
Among other criteria needed to qualify for an attempted vaginal breech delivery, the woman must have her pelvis measured via an MRI, and the baby must be full term and in frank or complete breech presentation. Very small or very large babies may not qualify. To find an appropriately trained doctor or midwife, call your closest academic health center and ask whether vaginal breech delivery is offered or whether they can refer you to providers who do offer it. You can also look for providers at midwife.org or birthpartners.org.
Published: March 10, 2013
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Birth